Employee Assistance Program (EAP)

ACA ShopCare: Employee Assistance Program (EAP)

Thank you for interest in the Auto Care Alliance's ShopCare EAP program. Please complete the form below to enroll employees into the program for only $30/year. Your program will start on the 1st of the month following your sign-up.

Company Name *
N/A
Company Address
N/A

Required Street Address Required City Required State/Region/Province Required Postal / Zip Code
Are you a member of one of the following? *
N/A

Yes - MWACA - Midwest Auto Care Alliance
Yes - MAACA - Mid-Atlantic Auto Care Alliance
Yes - NWACA - Northwest Auto Care Alliance
Yes - TXACA - Texas Auto Care Alliance
Yes - FLACA - Florida Auto Care Alliance
No - send me more information
Company Phone *
N/A

### ### ####
Company Contact
N/A

Required First Name Required Last Name
Company Contact Title *
N/A

Owner
Manager
Other
Company Contact Cell Phone Number *
N/A

### ### ####
Company Contact Email *
N/A
How many employees does your shop have? *
N/A
How many employees are you signing up from your shop? *
N/A
Employee Name
N/A

Required First Name Required Last Name
Employee Title *
N/A

Owner
Manager
Service Advisor
Technician
Other
Employee Personal Email *
N/A

required due to sensitive nature of communication
Employee Personal Cell Phone *
N/A

### ### ####
Do you have another employee to add? *
N/A

Yes
No
Employee Name
N/A

Required First Name Required Last Name
Employee Title *
N/A

Owner
Manager
Service Advisor
Technician
Other
Employee Personal Email *
N/A

required due to sensitive nature of communication
Employee Personal Cell Phone *
N/A

### ### ####
Do you have another employee to add? *
N/A

Yes
No
Employee Name
N/A

Required First Name Required Last Name
Employee Title *
N/A

Owner
Manager
Service Advisor
Technician
Other
Employee Personal Email *
N/A

required due to sensitive nature of communication
Employee Personal Cell Phone *
N/A

### ### ####
Do you have another employee to add? *
N/A

Yes
No
Employee Name
N/A

Required First Name Required Last Name
Employee Title *
N/A

Owner
Manager
Service Advisor
Technician
Other
Employee Personal Email *
N/A

required due to sensitive nature of communication
Employee Personal Cell Phone *
N/A

### ### ####
Do you have another employee to add? *
N/A

Yes
No
Employee Name
N/A

Required First Name Required Last Name
Employee Title *
N/A

Owner
Manager
Service Advisor
Technician
Other
Employee Personal Email *
N/A

required due to sensitive nature of communication
Employee Personal Cell Phone *
N/A

### ### ####
Do you have another employee to add? *
N/A

Yes
No
Employee Name
N/A

Required First Name Required Last Name
Employee Title *
N/A

Owner
Manager
Service Advisor
Technician
Other
Employee Personal Email *
N/A

required due to sensitive nature of communication
Employee Personal Cell Phone *
N/A

### ### ####
Do you have another employee to add? *
N/A

Yes
No
Employee Name
N/A

Required First Name Required Last Name
Employee Title *
N/A

Owner
Manager
Service Advisor
Technician
Other
Employee Personal Email *
N/A

required due to sensitive nature of communication
Employee Personal Cell Phone *
N/A

### ### ####
Do you have another employee to add? *
N/A

Yes
No
Employee Name
N/A

Required First Name Required Last Name
Employee Title *
N/A

Owner
Manager
Service Advisor
Technician
Other
Employee Personal Email *
N/A

required due to sensitive nature of communication
Employee Personal Cell Phone *
N/A

### ### ####
Do you have another employee to add? *
N/A

Yes
No
Employee Name
N/A

Required First Name Required Last Name
Employee Title *
N/A

Owner
Manager
Service Advisor
Technician
Other
Employee Personal Email *
N/A

required due to sensitive nature of communication
Employee Personal Cell Phone *
N/A

### ### ####
Do you have another employee to add? *
N/A

Yes
No
Employee Name
N/A

Required First Name Required Last Name
Employee Title *
N/A

Owner
Manager
Service Advisor
Technician
Other
Employee Personal Email *
N/A

required due to sensitive nature of communication
Employee Personal Cell Phone *
N/A

### ### ####
Terms and Conditions *
N/A

I understand I am committing to one year at $30 per employee for coverage effective January 1, 2023. Employee coverage is non-transferable and non-refundable.

I accept the Terms and Conditions.
Indicate the month you want EAP services to begin
N/A
Amount Due
N/A
$
$30 per employee
Payment *

Stripe USD

Amount to be paid $

Name on card
Date-Time
N/A

MM/dd/yyyy HH:MM AM/PM

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